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Prior Authorization for Meds

Insurance companies – those paying out money – understandably want patients to use the least expensive treatment possible. If the money was coming out of my own pocket, I’d definitely want to try a $20 treatment before shelling out $100 (or the $80 drug instead of the $2,500 drug).

When a rheumatologist writes a prescription for a biologic medication, it’s expected that the insurance company won’t authorize the pharmacy to fill the script without first making sure that less expensive treatments have proven ineffective. When I was first prescribed Enbrel, that prior-auth worried me. I’d heard from others about insurance companies dragging their feet and taking an excessively long time while patients sat and watched their fingers and toes become permanently misshapen. That worry was needless because everything went quite smoothly – it took two days.

Since then, I’ve changed pharmacies, insurers, and biologics, and discovered that things don’t always go that well. It would be nice if step one was for the doctor’s office to fax a form to get the process started with the insurer. Unfortunately, different insurers have different paperwork requirements, and it’s not realistic for a doctor to have on-hand the forms required by every insurer. It would also be nice if insurers – once they received information – dealt with the information promptly, but that doesn’t always happen, either.

I’ve learned so much about the way the procedure works – or doesn’t.

The first step is to make sure that the doctor is looking at an accurate record of past treatments. If you’ve ever changed doctors, there’s no guarantee (even if you provided all the information) that the information made it into your chart in the right format/location for your doctor to find that info when completing paperwork for the insurer. My rheumatologist looks at her prescribing history to determine how long patients have been taking a specific drug, so she hadn’t taken into consideration the year+ that I’d taken meds prescribed by someone else. It’s was a simple matter to add that information to the drug list so that it’s easily visible, but we had to first recognize it’s an issue.

The second step is to not dawdle in taking the script to a pharmacy. The sooner your pharmacy gets the third-party reject, the sooner things get moving. You can wait to contact the drug company for activation of a patient-assistance card until after leaving the prescription at the pharmacy.

Third, patients need to know how their insurer handles PA’s. This, I’ve discovered, is key. Some insurers want the pharmacy to contact the doctor, and some insurers want to do it themselves. Find out who sends that the fax your doctor, and see if there’s anything you can do to hurry the process along.

One Friday I went straight from my doctor’s office to the pharmacy with my new prescription. Ten days later I still hadn’t heard anything, so I phoned the insurance company to find out if there’s any way to speed the process up. When the doctor prescribes a med to be taken every two weeks and provides a sample for the first dose, it’s ridiculous for the insurer to wait more than three weeks to process the paperwork to get the patient those subsequent doses. That’s how long it took last time, and I was determined that this time would be different.

One would think that when the insurer tells the pharmacy that a PA is needed, the insurer would start working on it right away. Not so. My insurer could have – and should have – contacted my doctor promptly on Friday. It would be incredibly easy to program the computer so that a pharmacy reject would trip a flag; the computer would then automatically (immediately) fax a form to the doctor’s office to begin the paperwork process for approval. Instead, it’s a cumbersome process handled by snails, and my insurer didn’t even contact the doctor’s office until the following Wednesday.

The staff at my doctor’s office was expecting the insurance forms and returned them promptly; insurance logged receipt on Thursday – then did nothing. When I phoned (four days later), they couldn’t even find the forms. At least my call alerted someone to be looking, so this time it only took 17 days to get my approval.

I’m so glad I phoned, because I learned that patients can help the process along. I now have the direct phone number of one of the people who handles PAs for my insurance. I hope to not need another med change, but if I do, I can call him directly to expedite matters.

2 thoughts on “Prior Authorization for Meds”

I’ve had those delays, too. I swear the insurance hopes we’ll die or just go away before they have to pay! It would be easier if forms WERE standardized across all insurers, but that would be too sensible and take away one of their excuses! I feel sorry for the docs or their assistants having to re-sign & re-send forms when I’d rather they spent their time on patients.

What they finally approved bears little resemblance to what the doctor prescribed, too. And they approved 400mg every two weeks, but won’t allow 800mg per month; I can get 400mg every 15 days, though (um… shots every 14 days but fill every 15 days… how does that work?!). Drives me crazy.